Renal cell carcinoma

1. Renal cell carcinoma
management of RCC
Devana Lakshmi Narayana
FINAL YEAR MBBS

2. Approach considerations
• Laboratory investigation:
• Imaging modalities
• CT of the abdomen – preferably pelvic CT
• MRI –if venous involvement is suspected or patient cannot tolerate
contrast
• Chest CT or X-ray
• Excretory urography
• Renal arteriography
• Venography
• Bone scan
• Brain CT or MRI
• PETSCAN

3. CT and MRI
CT : IMAGING PROCEDURE OF CHOICE for diagnosis and
staging of RCC
 replaced excretory urography and renal USG
 it differentiates cystic mass from solid mass
 gives information about lymph node ,renal vein and
IVC involvement.

4. Percutaneous biopsy:
 Percutaneous cyst puncture and fluid analysis used in the
evaluation of potentially being malignant cystic renal lesions
 Also be detected by USG or CT
 Biopsy is especially important in pt with clinical or radiological
evidence of lymphoma, abscess or metastasis

5. HISTOLOGY
• Clear cell or conventional (75%of cases)
• Papillary (10-15%)
• Chromophobe (5%)
• Collecting duct (<1%)
• Translocation associated
• Tubulocystic
• Unclassified

6. TNM STAGING

7. TNM, AJCC STAGING (8TH EDITION 2018)

8. ROBSON –FLOCKS AND KADESKY STAGING

10. Principle treatment options for RCC
Surgery
Thermal ablation
Active surveillance
Radiation therapy
Immunotherapy
Molecular targeted therapy

11. SURGICAL- NEPHRON SPARING
NEPHRECTOMY
INDICATIONS:
1) T -1 Grade
2) Tumour restricted to poles
3) Bilateral tumours
4) RCC in a solitary functioning kidney
RELATIVE INDICATIONS:
• RCC in a kidney where C/L kidney affected by hydronephrosis or stones

12. Complications
• Lowest rate of serious complications
- post operative bleeding
- Inadvertent loss of kidneys
Advantages
• Patient with one kidney /pre existing CKD typically best managed with
OPEN PARTIAL NEPHRECTOMY to save kidney function as much as
possible .

15. RADICAL NEPHRECTOMY
• Indications :-
• Large renal cell carcinoma
• Severe trauma
• Renal infection- xantho granulomatous & Emphysematous-
pyelonephritis
• Refractory hypertension
• Infections due to Transplantation
• Recurring urinary infections
• Hematuria, Neutropenia,High proteinuria

16. RADICAL NEPHRECTOMY:
Structures removed are
• ENTIRE KIDNEY along with TUMOUR
• PERINEPHRIC TISSUE
• PROXIMAL 2/3RD URETER or AS LOW AS POSSISBLE
• PARAAORTIC LYMPH NODES & RENAL HILAR LYMPH NODES
APPROACHES:
• Open Radical nephrectomy
• Laparoscopic Radical nephrectomy

17. OPEN RADICAL NEPHRECTOMY

18. RADICAL NEPHRECTOMY

19. FOR METASTATIC TUMOURS:
1) Debulking surgery
2) mTOR inhibitors such as Sirolimus, Everolimus
3) Sunitinib, Sorafenib
4) IL-2

20. ACTIVE SURVEILLANCE AND ABLATIVE THERAPHIES
• RFA & CRYOTHERAPHY- Alternative strategy for elderly patients
competing health risks
limited life expectancy.
• Both can be performed using a laparoscopic or percutaneous approach under CT
or USG.
• CRYOTHERAPHY:
 Principle :- Rapid freezing & gradual thawing
Temperature -20 degree causes lethal damage to the cells
 An Ice ball is formed & the ablative margin lies within 3-5 mm of iceball
Indications :-
 T1a RCC where surgery cannot performed (ELDERLY PATIENTS)
Advanced / metastatic tumours ( as a palliative measure)

21. MEDICAL MANAGEMENT USING TARGETED THERAPHY
• 1st LINE MANAGEMENT: Tyrosine kinase inhibitors targeting VEGF
signalling access
• 2nd LINE SETTING: For treatment of metastatic RCC
-Sorafenib,Sunitimib,Lenvatinib
• In addition Anti VEGF Monoclonal Antibodies- Bevacizumab
approved for use with Interferon –alpha
• mTOR inhibitors –Everolimus & Temsirolimus are approved

22. CHEMOTHERAPY:
• Gemcitabine (IV 600mg/m2 on days 1,8 and 15)with continuous infusion of
5-Fluouracil ( IV150mg/m2/day for 21 days in a 28 cycle) with metastatic-
RCC Produced a response rate of 17 %
• Floxuridine
• cisplatin
• 5 Fluorouracil
• Gemcitabine
• Vinblastin
• Paclitaxel
• Carboplatin
• Ifosfamide
• Doxorubicin

23.  RADIOTHERAPY
• A dose of 4500 centigray (Boost upto 5500 cGY)
RENAL ARTERY EMBOLIZATION:
• With ethanol and Gelatin sponge pledgets
• Found effective for palliative treatment who are not candidates for surgery or
who refuse surgery
 PREVENTION OF RCC
LONG TERM MONITORING

24. Prevention of RCC
• Avoid causative factors
• Smoking
• Obesity
• Occupational exposures :-
Trichloroethylene,Benzene,Benzidine,cadmium,herbicides & vinyl
chloride
• Longer duration use of NSAIDS
• PHENACETIN containing analgesics
• Patients undergoing long term dialysis & Chronic hepatitis C infection

25. LONG TERM MONITORING
STAGE 1&2 RCC :- complete history, physical examination, chest -
radiographs, LFT ,BUN ,CREATININE LEVELS, SERUM CALCIUM LEVELS
• Recommended every 6 months for 2 years, then annually for 5 years
• Abdomen CT for every 4 to 6 months as indicated
STAGE 3 RCC :- as above
• Recommended every 4 months for 2 years ,then every 6 months for 3
years , then annually for 5 years
• Abdomen CT for every 4 to 6 months as indicated

26. Experimental therapeutic approach:
•Immunomodulatory drugs (lenalidomide)
•Vaccines
• Autologous tumor celled vaccine(RENIALE)
Improved the 5 year progression free survival
(PFS)at all tumor stages,when admimstered
after nephrectomy.
•Genetically modified tumor cell based
•Dendritic cell based vaccine
•Peptide based vaccine
•BCG vaccination

27. Stem cell transplantation
• Non myeloablative allogenic stem cell transplantation
Megestrol and Anti estrogens

28. REFERENCES
• BAILEY & LOVE 28TH EDITION
• SRB’S MANAGEMENT OF SURGERY 7TH EDITION
• SCHWARTZ principles of surgery
• NCBI.NLM.GOV RENAL CELL CARCINOMA (National institutes of
health -An official website of the USA Govt.,)
• Google images

29. Special mention to
DR.G.V.PRAKASH SIR